How to write a
best-seller about depression is a secret that was cracked by Flach nearly thirty
years ago when the first version of this book was published. Reading this
latest edition, it is easy to see why more than half a million copies have been
sold. His recipe for success is simple. He views unipolar depression as a
normal reaction to stress and not a form of mental illness. He mentions bipolar
depression on several occasions but recognises that it is a very different kind
of condition with a different aetiology and needing a different approach. This
book is aimed fairly and squarely at those who think that they might be
suffering from unipolar i.e. straightforward depression and those who have to
live with or cope with people suffering from such depression.

Flach insists that
depression is common and a normal part of most people's lives at one stage or
another. This approach is extremely positive and helpful. Treatment of
(unipolar) depression as a mental illness is thoroughly unhelpful for sufferers
because it deters them from asking for help. Insurance companies and employers
will almost always penalise them if their condition is included within the category
of mental illness. If we all treated depression as a normal reaction to stress
of one sort or another, everyone would benefit.

Not only does the
author see depression as normal but he also sees it as potentially healthy. It
is at this point that his distinction between acute depression and chronic
depression becomes important. Acute depression he sees as the perfectly normal
reaction to bereavement, divorce, job loss, retirement, etc. It is not being
depressed under such circumstances that is the problem. The problem arises only
when the sufferer fails to face up to and come to terms with the cause of the
depression. When that happens the depression may, so to speak, go underground.
That is when it transmutes into chronic depression which is a more difficult
condition to treat.

Flach views
depression in an unusually holistic way. He lays great emphasis on the links
between the psychological, environmental/social and the physiological aspects.
The psychological aspect is perhaps obvious but the author covers some unusual
ground, touching upon, for example, the potentially positive role of guilt and
the contribution that a spiritual view of life can make. He is acutely aware of
the environmental/social factors which can either support a person suffering
from depression or, at the opposite extreme, can actually provoke depression.
His description of what he calls depressogenic environments is extremely
enlightening. A family member can, by destructive behaviour, cause a whole
household to become a depressogenic environment and many of us will have come
across such a person and the harm that s/he can do. Perhaps even more
illuminating is the author's description of the workplace where, because of the
attitudes of someone near or at the top of the hierarchy, a depressogenic
environment is created. People working in such an environment either have to
leave to find employment in a more positive structure or bit by bit they succumb
and can end up chronically depressed. The third aspect, the physiological, is
an area where the author has himself been involved in considerable research.
His main area of research has been in the changes to calcium metabolism in
patients suffering from depression. There is evidence that depression is linked
to an increase in calcium in the coronary arteries and that, as the depression
is lifted, the free floating calcium is re-deposited in bone. This is a complex
area and is linked to a wide variety of other physical factors such as the
level of cortisol in patients suffering from stress-related depression.
However, it is good to see such a holistic approach. As the author states, "…
it remains essential to view the human being as a whole – mind, body, inner
world, outer world, acting, reacting, interacting, creating." (p.202)

Largely because of
this holistic view, Flach is particularly open to using a wide variety of
methods to help patients suffering from depression. He is not sympathetic to
traditional i.e. Freudian psychoanalytical approaches but he is supportive of
all less narrow, more eclectic and more all-embracing forms of psychotherapy. He
recommends family counselling when it seems appropriate. He is very
knowledgeable, as one would expect of a practising psychiatrist, about all the
drugs available and their good and bad points. He is aware of the complex interplay
between physical symptoms and psychological causes and as a result he is also
aware of the 'chicken and egg' question as to which one is causing the other
but he is adamant that the wise use of drugs can be a helpful part of the
treatment of depression. He mentions Electric Convulsive Therapy (ECT) and the
newer and less drastic [rapid-rate] Transcranial Magnetic Stimulation (rTMS)
only in connection with extreme cases of bipolar depression but he states that
they can be very effective forms of treatment. It is up to readers whether they
agree with Flach's support of ECT. Many workers in the mental health field
to-day have extreme reservations about its use.

The author's
distinction between acute and chronic depression is usefully applied in several
areas and linked with, for example, post-traumatic stress disorder. The
difficulties involved in diagnosing and then treating chronic depression are
well-described. Particularly good is his analysis of how people often engage in
behaviour which traps them in a self-reinforcing depressive situation.

Flach devotes
several chapters to particular problem areas. The chapter on sex and the sexual
demands made of people these days has a very contemporary feel to it. Equally
useful is the chapter on anger and how, on the right occasions, it can be the
right reaction to a situation. The chapter on work and especially the pressure
to succeed at high-powered jobs is sobering and should be read by everyone
putting in fourteen hour days! The author is very sensitive to the delicate
balance needed between marital partners if both are to remain mentally healthy
with the result that he has a very good chapter on dependency. Other excellent
chapters are on childhood and adolescence. The chapter about the elderly contains
some particularly sage advice concerning retirement.

Flach's insistence
on depression as being a normal reaction to highly stressful occasions, his
distinction between acute and chronic depression, his holistic approach to
supporting people suffering from depression and his positive view of depression
as an opportunity for personal growth make this a highly recommended book for
anyone suffering from or interested in depression. The book will almost
certainly go into yet another edition, as it surely deserves, and this should
give the publishers the opportunity to correct the typos which have crept in,
especially the use of 'martial' for 'marital' on p.105 although the concept of 'martial
infidelity' may well be worth thinking about!

Kevin
Purday is Head of the CambridgeInternationalHigh
School and is currently a
distance-learning student on the Philosophy & Ethics of Mental Health
course in the Philosophy Dept. at the University of Warwick.

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